GW1-2021-01991_Well Construction - GW1_20210620

Print Form
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well
tContractor /^�Information::
M\) /r ► v ' y o u 1 V 1 1 p `14.WATER ZONES .
Well Cont``L1 C�J� FROM TO DESCRIPTION
tor��
t ft
ft. ft
NC Well Contractor Certification Number .11 OUTER CASING(formulti-cased wells OR LINER if a livable
Morgan Well &Pump, Inc. FROM To DIAMETER THICIOVESS MATFurat
+1 fL fL 6 1/8/ in' sdr2l pvc
Company Name �/.-
C.1 16:INNER CASING OR TQBING``eoth"ermal closed-loo >.
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits rz.e.UIC,County,State,Variance,etc.) ft fL in.
3.Well Use(check well use): fL fL in.
17
Water Supply Well: FROM-SCREE
TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
Agricultural OMunicipal/Public ft ft is
Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single) ft fL in.
Industrial/Commercial E3Residential Water Supply(shared) b 18:GROUT
'Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL PO fL bentonite poured
:')Monitoring QRecovery fL ft.-
Injection Well: fL fL
Aquifer Recharge OGroundwater Remediation
-:19:SAND/GRAVEL'PACK if a livable '
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
_ Aquifer Test Stormwater Drainage ft ft
Experimental Technology Subsidence Control fL ft
Geothermal(Closed Loop) Tracer �211.DRII LING.LOG'attach'additlonsl stieets-ff uecess s
Geothermal(Heating/Cooling.Conlin Return) Other(explain under#21 Remar FROM TO DESCRIPTION(color,hardness,soil/rock a rain size,eta)
— ,] ft 6 ft ,
4.Date Well(s)Completed: Jti We11ID# J fL (Sc. ft o� ,
5a.Wel tell Location: ft t f
I(mot �"�U✓y Cti1 /Ac' 4w V ft ft 'J�
Facility/Owner Name Facility #(if applicable)
G ft ft
A /`7Gb/YS(./l� ft. ft
R EC
Physical
Address,City,and Zip / /f/ ft ft
Y✓ C f/ Q. �1 �b� 74 n7S 21.�RF.MARKC .: _ - -
County �— Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Information prrJCessin unll
(ifwell field,one lat/long is sufficient) 22 Ication: DWR Sedion
31S STLZ-7�_N
6.Is(are)the well(s)foPermanent or OTemporary Signature of ertified Well Contract Date
By signing this farm,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: nYes or JSNo with 15A NCAC 01C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
If this is a repair,fell out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 G -1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �`' (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'ald 2@1001 construction to the following:
10.Static water level below top of casing: o (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
O above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY QWELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: air pressure 24c.For Water Supply&Iniection Wells: In addition to sending the form to
f the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:_ r44V 16Lr Amount: 1 + completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016